San Pedro Workshops Retreat Enrollment Form

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Name

First

Last

Age

Gender

Male
Female
Other

Birthdate

Email

Have you tried San Pedro and/or Ayahuasca before?

Yes
No

If so, please state which one and how many times

Do you suffer from schizophrenia or have been diagnosed with it in the past?

No
Yes

Do you currently suffer from any other significant physical or psychological conditions?

Yes
No

If so, please state which ones

Are you currently (or in the last 30 days) been taking any medication that affects brain function such as anti-depressants, anti-psychotics or anti-anxiety medications?

Yes
No

If so, which ones?

Which of our workshops would you like to attend?

On which dates would you like to come for the workshop?

Please explain the reasons why you would like to sign up for one of our workshops. You can be as thorough and detailed as you like